Purpose: The purpose of our study was to evaluate the usefulness of dynamic cine MRI during respiration in the assessment of chest wall invasion by lung cancer. Materials and Methods: We prospectively performed respiratory dynamic MRI in 34 patients with peripheral lung cancer, in whom the presence of chest wall invasion was indeterminate on CT. Sequential images were obtained during respiration by using fast spoiled GRASS (SPGR) sequence, and were analyzed in cine mode display. Results: In all 23 patients with free movement of the tumor along the chest wall on respiratory dynamic cine MRI, no chest wall invasion was found at surgery (negative predictive value 100%). In eleven patients with fixation of the tumor to the chest wall, invasion was confirmed pathologically in five patients, while benign fibrous adhesion was found in six. Conclusion: Although it has some limitations, dynamic cine MRI during respiration is useful in evaluating chest wall invasion in patients with lung cancer, particularly when CT findings are indeterminate

Abe Kuniko

Abiru Hajime

Akamine Shinji

Ashizawa Kazuto

Fukushima Aya

Hayashi Hideyuki

Hayashi Kuniaki

Hayashi Tomayoshi

Matsuyama Naohiro

Muraoka Masashi

Nagayasu Takeshi

Oka Tadayuki

Tagawa Tsutomu

Yamaguchi Tetuji

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Acta Med. Nagasaki 48: 143-147Chest Wall Invasion by Peripheral Lung Cancer: Preoperative Assessment with Respiratory Dynamic MRIKazuto ASHIZAWA1), Masashi MURAOKA 2), Hideyuki HAYASHI 3), Tetuji YAMAGUCHI1), Aya FUKUSHIMA 1), Naohiro MATSUYAMA 1), Hajime ABIRU 1), Shinji AKAMINE 2), Tsutomu TAGAWA 2), Tadayuki OKA 2), Takeshi NAGAYASU 2), Kuniko ABE 3), Tomayoshi HAYASHI 3), Kuniaki HAYASHI 1)1) Division of Radiological Science, Department of Radiology and Radiation Biology, Nagasaki University Graduate School of Biomedical Sciences 2) Division of Surgical Oncology, Department of Translational Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences 3) Department of Pathology, Nagasaki University HospitalPurpose: The purpose of our study was to evaluate the use-fulness of dynamic cine MRI during respiration in the as-sessment of chest wall invasion by lung cancer. Materials and Methods: We prospectively performed respi-ratory dynamic MRI in 34 patients with peripheral lung cancer, in whom the presence of chest wall invasion was indeterminate on CT. Sequential images were obtained dur-ing respiration by using fast spoiled GRASS (SPGR) se-quence, and were analyzed in cine mode display. Results: In all 23 patients with free movement of the tumor along the chest wall on respiratory dynamic cine MRI, no chest wall invasion was found at surgery (negative predic-tive value 100%). In eleven patients with fixation of the tumor to the chest wall, invasion was confirmed pathologi-cally in five patients, while benign fibrous adhesion was found in six. Conclusion: Although it has some limitations, dynamic cine MRI during respiration is useful in evaluating chest wall invasion in patients with lung cancer, particularly when CT findings are indeterminate.     ACTA MEDICA NAGASAKIENSIA 48: 143-147, 2003resection is performed, the operative risk for mortality is still substantial'-". Therefore, preoperative evalua-tion of chest wall invasion is important in planning the treatment and assessing the prognosis of the pa-tient with lung cancer.  Conventional CT'-" and MRI 7 -'°' have been used to evaluate chest wall invasion by lung cancer. Several CT features have been proposed and evaluated as di-agnostic criteria for invasion. However, distinction be-tween tumoral contiguity with the pleural surface and actual tumor invasion is frequently difficult. Previous reports showed low accuracy of CT' - 7,1-13' and MRI 7 -10' based on static images.  Recently, Sakai et al.") reported a new MR tech-nique with dynamic imaging during respiration and showed 100% high sensitivity and 100% negative pre-dictive value (NPV). In this study, we prospectively evaluated the usefulness of this technique in the diag-nosis of chest wall invasion, focusing on difficult cases in which tumor invasion was indeterminate on CT.Key Words: lung cancer, chest wall invasion, MRI, respiratory            dynamic studyIntroduction Chest wall invasion by lung cancer is one of the in-dications for extended surgery. Although these pa-tients can achieve long-term survival when completeAddress Correspondence: Kazuto Ashizawa, M.D. Division of Radiological Science, Department of Radiology and Radiation Biology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan TEL: +81-95-849-7355, FAX: +81-95-849-7357 E-mail: ashi@net.nagasaki-u.ac.jpMaterials and Methods Between 1997 and February 2001, 48 consecutive patients with peripheral lung cancer that abutted the chest wall on CT images were prospectively studied with respiratory dynamic MRI after routine chest MRI. 14 patients were excluded from this study. 10 of these patients did not undergo surgery due to lymphnode or distant matastasis or high age, and 2 patients had evidence of rib destruction or a chest wall mass on CT images. In the remaining 2 patients, chest wall invasion was not suspected based on previ-ously reported diagnostic criteria of CT features" 6, Therefore 34 patients in whom the presence of chest wall invasion was indeterminate on CT images were included in this study. One or more CT features ofKazuto Ashizawa et al : Chest Wall Invasion by Lung Cancer: Assessment with Respiratory Dynamic MRIchest wall invasion (obtuse angle of the mass to the pleural surface, more than 3 cm contact with the pleu-ral surface, visible pleural thickening associated with the mass, and obliteration of the extrapleural fat plane) were present in all patients"'). These patients were 32 men and two women, ranged in age from 45-81 years (average, 66 years). Tumors included 16 squamous cell carcinomas, 10 adenocarcinomas, 4 large cell carcinomas, 3 adenosquamous cell carcino-mas and 1 mucoepidermoid carcinoma. The presence or absence of chest wall invasion was confirmed surgi-cally and/or pathologically in all of the patients.  Respiratory dynamic MRI was performed with 1.5-T MR system (Signa Horizon, GE Medical Systems, Milwaukee, WI, USA). Fast spoiled GRASS (SPGR) se-quence was obtained at TR 8.9ms, TE 4.2ms and FA 30 deg. Field of view of 30cm, matrix of 256 x 128, and slice thickness of 7mm were used. Thirty sequen-tial images during deep respiration were obtained in the coronal or sagittal planes, according to the loca-tions of tumors.  Two radiologists analyzed the dynamic relationship between the tumor and the chest wall in the cine-loop mode on a CRT monitor. When the tumor moved freely along the parietal pleura, it was judged as nega-tive for chest wall invasion. When the tumor was fixed to the chest wall structures, it was judged as positive for invasion. Respiratory dynamic MRI find-ings were then compared with the surgical and patho-logical findings. We evaluated chest wall invasion by the tumor that was located in the apical portion sepa-rately, because the movement of the lung along the chest wall is small even in normal individual.34 patients were judged as negative for invasion be-cause of free movement of the tumor on respiratory dynamic MRI. None of them had evidence of chest wall invasion at surgery (Fig 1). The other 11 patients demonstrated fixation of the tumor to the chest wall, and were judged as positive for tumor invasion. Pathological examination revealed that 5 of the 11 pa-tients had chest wall invasion (Fig 2), but 6 patients had benign fibrous adhesions (Fig 3). The sensitivity, specificity, accuracy and NPV were 100%, 79%, 82% and 100%, respectively. Three patients with the tumorResults The dynamic MRI findings and the pathological findings are compared in Table 1. Twenty-three of theTable 1. Comparison of respiratory dynamic MRI and patho-logical findings                                Pathological finding Respiratory dynamic MRI finding Invasion No invasion    Fixation 5 6    Free movement 0 23Sensitivity 100%, Specificity 79%, Accuracy 82%, PPV 45%, NPV 100%Figure 1. 57-year-old man with squamous cell carcinoma. A: CT scan shows a cavitary mass as having a broad contact with the pleural surface, obtuse angle and partial obliteration of the extrapleural fat plane. B: Respiratory dynamic MR images show free movement of the tumor along the chest wall, indicating no tumor invasion into the chest wall.Kazuto Ashizawa et al : Chest Wall Invasion by Lung Cancer: Assessment with Respiratory Dynamic MRIFigure 2. 64-year-old man with adenocarcinoma. A: CT scan shows a mass as having a broad contact with the pleural surface, associated pleural thickening and obliteration of the extrapleural fat plane. B: Respiratory dynamic MR images show that the relation-ship between the tumor and the chest wall is fixed. The tumor invasion into the chest wall was confirmed pathologi-cally.Figure 3. 80-year-old man with adenocarcinoma. A: CT scan shows a mass as having a broad contact with the pleural surface, obtuse angle and associated pleural thicken-ing. B: Respiratory dynamic MR images show fixation of the tumor during respiration. Although tumor invasion into the chest wall was suspected preoperatively, benign fibrous adhe-sion was confirmed pathologically.located in the apical portion were judged as positive for invasion. Two of these cases had chest wall inva-sion and the other one had benign fibrous adhesion pathologically.Discussion Conventional CT and MRI have widely been used to evaluate chest wall invasion by lung cancerKazuto Ashizawa et al : Chest Wall Invasion by Lung Cancer: Assessment with Respiratory Dynamic MRIpreoperatively'-"'. When bone destruction or a chest wall mass is observed, the presence of chest wall inva-sion can be confidently diagnosed on CT. However several authors have reported low accuracy of CT and MRI in prediction of chest wall invasion'-"'. CT fea-tures that have been proposed and evaluated as diag-nostic criteria for invasion are as follows: obtuse angle of the mass to the pleural surface, more than 3 cm contact with the pleural surface, visible pleural thick-ening associated with the massy', obliteration of the extrapleural fat plane, or the ratio between the tumor-pleura contact and tumor diameter". However, distinc-tion between tumoral contiguity with the pleural sur-face and actual tumor invasion is frequently difficult with these criteria by static images.   In contrast to conventional static imaging, dynamic imaging during breathing can provide direct informa-tion about the presence or absence of attachment be-tween the visceral and parietal pleura, and can im-prove diagnostic accuracy for chest wall invasion by lung cancer. Several authors have reported respiratory dynamic methods using ultrasonography15', helical CT during deep inspiration and expiration"', ultrafast CT with multisection expiratory dynamic scan"' and res-piratory dynamic MRI14, 18). All of these reports have shown high sensitivity (100%) and NPV (100%) of these methods for diagnosing chest wall invasion.  Artificial pneumothorax CT also enables a kind of dynamic assessment of chest wall invasion by lung cancer 19' 20'. Yokoi et al. reported that this method was 100% accurate in prediction of tumor invasion"'. However, this technique is invasive and may result in symptomatic pneumothorax. In addition this technique may fail to produce artificial pneumothorax. In con-trast, respiratory dynamic MRI is a quick, noninvasive examination, and can easily be performed after rou-tine chest MRI.  We performed dynamic cine MRI in patients in whom the presence of chest wall invasion was indeter-minate on static CT images, and sensitivity (100%) and NPV (100%) were comparable with the other respira-tory dynamic methods in assessing tumor invasion. However, this method has some limitations in its diag-nostic ability similar to the other reported dynamic methods. One limitation is the difficulty in distinction between actual tumor invasion and a benign fibrous adhesion"'. In our study, 6 out of 11 patients with fixation of the tumor to the chest wall had benign fi-brous adhesions. In 3 of the 6 patients, however, possi-bility of benign adhesions was considered because the tumor was not completely but partially fixed to the adjacent structures. Another limitation is that evalua-tion of the tumor invasion is difficult when the tumoris located in the apical portion, because of less relative movement of the lung during respiration","'. Although no patients with the tumor located in the apical por-tion were judged as negative in our study, this method may be superior to compared to other breath-ing dynamic methods because even a subtle move-ment of the lung could be observed in the cine mode display".  In conclusion, respiratory dynamic MRI is a quick, noninvasive examination, and our results indicate that this method is helpful in the evaluation of chest wall invasion by lung cancer, especially in patients in whom conventional CT findings of tumor invasion are indeterminate.Acknowledgment We thank Dr. Rashid Hashmi for his assistance in the preparation of this manuscript.References1. Roviaro G, Varoli F, Grignani F, et al. 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Chest Wall Invasion by Peripheral Lung Cancer: Preoperative Assessment with Respiratory Dynamic MRI

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Chest Wall Invasion by Peripheral Lung Cancer: Preoperative Assessment with Respiratory Dynamic MRI

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